India's healthcare system is extremely inefficient especially for those suffering from any form of mental illness. The care facilities are improper coupled with a plethora of intricacies that makes matter even worse for individuals suffering from mental ailments.
By Shishir Somani
Raj was diagnosed with a mental disorder called Schizophrenia in 1991 and the treatment started immediately in a premier national institute. However, like most psychiatric patients, he goes off medication very often and needs to be hospitalized with police help. He lives with his widowed mother and two sisters and the family dynamics is not conducive to his progress. In 2007-08, he once again had a relapse because of stopping medicines; and was very disturbed and angry. But the police refused to shift him this time. The psychiatrist wrote a letter to the magistrate to issue a Reception Order for the police to shift him to the hospital as per law. However, the magistrate wanted to see Raj in the court before issuing the order. The police were unable to pick him up because of his threats to commit suicide or attack someone at home. Eventually he attacked his sister; The police asked the family to file an FIR for criminal assault which they did. The family moved out of the house; Raj was picked up by the police, produced before the magistrate, who refused to believe that he was mentally ill. Hence Raj was sent to the jail for criminal activity. The jailer finds him suffering from acute psychosis and so gets him into the psychiatric hospital. He was back to "normal" after a month's treatment. If only there was some crisis and emergency help available in 2008, Raj could have been shifted to the hospital without being declared a criminal with jail records! The hospital could have also admitted him under temporary treatment order under the law instead of asking for Reception Order. Though the law permits 90 days hospitalization under this order, many psychiatrists prefer to make the family get a Reception Order. The above case illustrates how isolation from mainstream health services can adversely impact mentally-ill patients in India. Here, the majority of the prevailing 65 million persons with mental disorders are dependent on public health services. Of the 65 million, 15 million are afflicted with severe psychosis; 30 to 50 million suffer from mild to moderate psychiatric disorders.
Integration of mental health with general health needs training for the medical practitioners to diagnose co-morbidity of mental disorders with physical ailments at the PHC level. Inclusion of Psychiatry as a credit course in MBBS would have reduced the burden of OJT for the PHC doctors. Strangely enough, this is not happening, despite court orders, due to consistent lack of coordination between the Department of Medical Education and the Health Ministry. As on March, 2008, 1,46,036 Sub-Centers, 23,458 PHCs and 4,276 CHCs are functioning in the country with only 13 percent of the PHCs without a doctor. The alarming deficiency in mental health is a shortage of 7,000 psychiatrists, but even the existing 2,800 are inequitably distributed with a majority in urban areas; whereas 80 percent of the potential and existing patients are rural-based. Recently, the MoH, under the Delhi High Court orders, facilitated an addition of 125 seats per year in PG Psychiatry but the need is for 7,000 psychiatrists. Deficiency among the support staff is even more startling. Yet, there is neither a policy, nor a program to galvanize mental healthcare through public health system in PHCs.
Mental health has never been a priority for the Health Ministry though India pioneered PHC-level psychiatric treatment in the early 1970s, followed by the Bellary project that pilot-tested the District Mental Health Program (DMHP) in 1980. But, DMHP had failed to achieve total coverage of 600 districts even by 2000. Allocation of Rs. 1000 crore under the 11th Plan is commendable; but the Planning Commission's "EMI" style of funding is a frightening exercise. Hundred districts per plan period is the average intake of the program, leaving the rest for subsequent phases.
The 2008 mid-term evaluation of the DMHP highlights the disastrous results of delinking of mental health from the District health systems. Underutilization of DMHP funds by the state governments continues to be the pattern on account of inability to plan with a global perspective at the national level. It is also amazing to note the uneven performance profile of state governments. Tamil Nadu has almost 16 DMHP districts, UP has 12 compared to four each in Karnataka and Assam. There is no structural linkage with the grassroots either through the ANMs of the district health program or the AASHA workers under NRHM, accounting for its top-heavy medical — instead of community — and family-centric model. Nearly 80 per- cent of mental patients live with their families and yet the DMHP does not talk of a single family caregiver or patient training program.
NMHP is a medical monolith unlike the TB, Cancer and HIV/AIDS programs where the social component ranks foremost in the community projects. The Rs. 1000-crore budget under the 11th Plan is also woefully inadequate in view of the target population of 60 to 65 million MI persons. As a striking contrast, we find a budget of Rs. 1,447 crores for TB (1.9 million cases in 2007), Rs. 2,400 crore for cancer (2.5 million patients) and INR 1,100 for three million HIV/AIDS cases (in addition to global funding).
The success stories of these programs call for a complete organizational, administrative and financial revamping of NMHP under a dedicated national level nodal agency like the NACO with wider participation from civil society. n
Integration of mental health with general health needs training for the medical practitioners to diagnose co-morbidity of mental disorders with physical ailments at the PHC level.
Mental matters
